DEFENSE HEALTH 

CARE

More-Specific

Guidance Needed for 

Assessing 

Nonenrolled 

TRICARE 

Beneficiaries’ Access 

to Care

Report to Congressional Committees

April 2014

GAO-14-384

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-384, a report to 

congressional committees

April 2014

DEFENSE HEALTH CARE

More-Specific Guidance Needed for Assessing 

Nonenrolled TRICARE Beneficiaries’ Access to Care

Why GAO Did This Study

DOD provides health care through 

TRICARE, its regionally structured 

health care program. In each of its 

regions (North, South, West), DOD has 

a TRO that oversees health care 

delivery. Beneficiaries who choose the 

TRICARE Prime option must enroll. 

Beneficiaries who do not enroll may 

obtain care under the TRICARE 

Standard, Extra, or Reserve Select 

options—referred to as nonenrolled 

beneficiaries. Since TRICARE’s 

inception in 1995, nonenrolled 

beneficiaries have complained about 

difficulties finding civilian providers who 

will accept them as patients.

The National Defense Authorization 

Act for Fiscal Year 2008 mandated that 

GAO evaluate the processes, 

procedures, and analyses used by 

DOD to determine the adequacy of 

access to care for these beneficiaries. 

This report addresses the extent to 

which the TROs have assessed 

nonenrolled beneficiaries’ access to 

care. To conduct this work, GAO 

reviewed and analyzed relevant 

documentation and interviewed DOD 

officials, including officials in each of 

the TROs. In addition, GAO reviewed 

federal internal control standards for 

monitoring performance. GAO also 

interviewed officials from organizations 

representing military beneficiaries to 

discuss their perspectives on the 

TROs’ efforts.

What GAO Recommends

GAO recommends that DOD enhance 

existing guidance for the TROs to 

include more specificity on assessing 

nonenrolled beneficiaries’ access to 

care. DOD concurred with GAO’s 

recommendation.

What GAO Found

The Department of Defense (DOD) has devoted significant resources over the 

past decade—largely through national surveys of beneficiaries and civilian 

providers—in determining whether nonenrolled beneficiaries (those not enrolled 

in TRICARE Prime) have adequate access to health care. However, the lack of 

access standards for this population has significantly limited the department’s 

ability to make these determinations. In 2010, the Deputy Chief of TRICARE 

Policy and Operations issued an action memo that outlined a series of 

recommendations for how the TRICARE Regional Offices (TRO) should gauge 

nonenrolled beneficiaries’ access to care. Two of the memo’s 

recommendations—analyzing the results of DOD’s national surveys and using 

beneficiary-to-provider population models—provide a strategy for monitoring and 

assessing nonenrolled beneficiaries’ access to care. However, GAO found that 

these recommendations do not include sufficient guidance that specifies what 

process to follow in determining whether nonenrolled beneficiaries’ access to 

care is adequate. According to federal internal control standards, having a 

monitoring strategy that includes specific guidance is important for leadership to 

ensure that ongoing monitoring is effective and will trigger separate evaluations 

when problems are identified.

In the absence of more-specific guidance, GAO found that the TROs’ efforts to 

implement the action memo’s recommendations have resulted in limited and 

inconsistent methods for identifying and addressing areas with potential access 

problems, which in some instances have included the use of judgment in place of 

clear criteria for making these determinations. For example:

• One recommendation advises the TROs to report on the results of the 

access questions from the nonenrolled beneficiary survey for their region, 

and to include any subsequent action plans to address the potential access 

problems they identify. GAO found that the TROs varied in the extent to 

which they used the survey data to identify potential problem areas, and 

none of them had a clearly documented methodology for how they used 

these data, including a rationale for when further actions should be taken. 

• Another recommendation advises the TROs to establish a working group to 

adapt and standardize a beneficiary population-to-provider model to 

determine whether there are sufficient numbers of civilian providers to 

provide reasonable access to care. However, GAO found that only one of the 

TROs applied criteria to its population-to-provider ratios, and while this TRO 

identified areas with potential access problems, officials told GAO that they 

ultimately used their judgment to determine that no access problems existed 

because they had not received beneficiary complaints from these areas.

Without more-specific guidance, DOD does not have reasonable assurance that 

the TROs’ efforts to assess access to care for nonenrolled beneficiaries are 

effective or that its own efforts to field and analyze large, costly, national surveys 

are providing useful data.

View GAO-14-384. For more information, 

contact Debra Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-14-384 Assessing Access to Care

Letter 1 

Background 5

The TROs’ Efforts to Assess Nonenrolled Beneficiaries’ Access to 

Care Have Been Limited and Inconsistent due to Insufficient 

Guidance 11

Conclusions 17

Recommendation for Executive Action 18

Agency Comments 18

Appendix I Benchmarks for TRICARE Management Activity’s 2008 through 2011 

Surveys 20

Appendix II Comments from the Department of Defense 23

Appendix III GAO Contact and Staff Acknowledgments 25

Tables

Table 1: Summary of TRICARE Benefit Options 6

Table 2: TRICARE Management Activity (TMA) Benchmarks for 

Its 2008 through 2011 Nonenrolled Beneficiary Surveys 20

Table 3: TRICARE Management Activity (TMA) Benchmarks for 

Its 2008 through 2011 Civilian Provider Surveys 22

Figures

Figure 1: Types and Percentages of Nonenrolled TRICARE 

Beneficiaries 7

Figure 2: Location of TRICARE Regions in the United States 8

Contents
Page ii GAO-14-384 Assessing Access to Care

Abbreviations

BRAC Base Realignment and Closure

CAHPS Consumer Assessment of Healthcare Providers 

and Systems

DHA Defense Health Agency

DOD Department of Defense

HHS Department of Health and Human Services

NDAA 2008 National Defense Authorization Act for Fiscal Year 2008

non-PSA non-Prime Service Area

PSA Prime Service Area

TMA TRICARE Management Activity

TRO TRICARE Regional Office

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-14-384 Assessing Access to Care

441 G St. N.W.

Washington, DC 20548

April 28, 2014

The Honorable Carl Levin

Chairman

The Honorable James Inhofe

Ranking Member

Committee on Armed Services

United States Senate

The Honorable Howard P. “Buck” McKeon

Chairman

The Honorable Adam Smith

Ranking Member

Committee on Armed Services

House of Representatives

In fiscal year 2013, the Department of Defense (DOD) offered health care 

services to almost 9.6 million eligible beneficiaries in the United States 

and abroad through TRICARE, its regionally structured health care 

program.1 Under TRICARE, beneficiaries may obtain health care either 

from military hospitals and clinics, referred to as military treatment 

facilities, or from civilian providers. DOD’s Defense Health Agency 

(DHA),2

 

1

Generally, eligible beneficiaries include active duty personnel and their dependents, 

medically eligible National Guard and Reserve servicemembers and their dependents, 

and retirees and their dependents and survivors. Active duty personnel include Reserve 

component members on active duty for at least 30 days. The TRICARE program provides 

health care services in overseas regions called “areas” in Eurasia-Africa, Latin America 

and Canada, and the Pacific. These areas are beyond the scope of this report.

which oversees the program, uses managed care support 

contractors (contractors) to develop networks of civilian providers—

referred to as network providers—to serve all TRICARE beneficiaries in 

2

Prior to October 1, 2013, the TRICARE Management Activity (TMA) oversaw the 

TRICARE program. In response to increasing pressure on its budgetary resources, DOD 

established the DHA on October 1, 2013, to assume management responsibility of 

numerous functions of its medical health system, including the former TMA, which was 

terminated on that date. For additional information about the establishment of DHA, see 

GAO, Defense Health Care Reform: Additional Implementation Details Would Increase 

Transparency of DOD’s Plans and Enhance Accountability, GAO-14-49 (Washington, 

D.C.: November 2013).
 

Page 2 GAO-14-384 Assessing Access to Care

geographic areas called Prime Service Areas (PSA).3

The number and type of civilian providers available to serve TRICARE 

beneficiaries can vary depending on a beneficiary’s location and choice of 

coverage among TRICARE’s three basic options—TRICARE Prime, 

TRICARE Standard, and TRICARE Extra.

The contractors 

also perform other customer service functions, such as processing claims 

and assisting beneficiaries with finding providers. Each TRICARE region 

(North, South, and West) within the United States has a contractor, as 

well as a TRICARE Regional Office (TRO) that oversees health care 

delivery within its respective region. Each TRO monitors the regional 

contractor’s performance, including its ability to achieve and maintain an 

adequate civilian provider network.

4 Beneficiaries who live in a 

PSA may choose to enroll in TRICARE Prime, a managed care option;5

however, this option is not typically available to beneficiaries living outside 

of a PSA. Beneficiaries do not need to enroll in TRICARE Standard (a 

fee-for-service option) or TRICARE Extra (a preferred provider 

organization option) and can choose to receive care either through 

TRICARE Standard when they are seeing nonnetwork civilian providers 

or through TRICARE Extra when they are seeing network civilian 

providers.6

 

3

PSAs are geographic areas determined by the Assistant Secretary of Defense for Health 

Affairs and are defined by a set of five-digit zip codes, usually within an approximate 

40-mile radius of a military treatment facility. In addition to developing networks of civilian 

providers in PSAs around these facilities, the managed care support contracts also require 

the contractors to develop these networks at all Base Realignment and Closure (BRAC) 

sites, which are military installations that have been closed or realigned as a result of 

decisions made by the Commission on Base Realignment and Closure. Contractors are 

not required to develop networks in areas outside of PSAs—called non-PSAs—but have 

done so in some locations.

We use the term “nonenrolled beneficiaries” in this report to 

refer to beneficiaries who are not enrolled in TRICARE Prime and who 

use TRICARE’s Standard or Extra options and to beneficiaries who are

4

TRICARE has several other plans, including TRICARE Young Adult-Standard Option (for 

beneficiaries’ dependents up to age 26) and TRICARE Reserve Select (for certain 

National Guard and Reserve servicemembers), which are similar to TRICARE Standard 

and Extra in terms of benefits to the beneficiary.

5

Active duty servicemembers are required to use TRICARE Prime.

6

Nonnetwork civilian providers are those providers that are not in the TRICARE network, 

but are certified to see TRICARE patients.
 

Page 3 GAO-14-384 Assessing Access to Care

enrolled in TRICARE Reserve Select.7

Since TRICARE’s inception in 1995, nonenrolled beneficiaries have 

complained about difficulties finding civilian providers who will accept 

them as patients. However, it has been difficult for DOD to determine the 

type and extent of access problems for this population because unlike 

TRICARE Prime, there are no established access standards for the 

TRICARE Standard and Extra options.

At the end of fiscal year 2013, 

there were about 2.2 million nonenrolled beneficiaries, about 67 percent 

of which were retirees and their dependents or survivors.

8 To determine the adequacy of 

access to civilian health care providers for nonenrolled beneficiaries 

under TRICARE, the National Defense Authorization Act for Fiscal Year 

2008 (NDAA 2008) directed DOD to conduct annual surveys over 4 years 

of both nonenrolled beneficiaries and civilian providers.9 It also mandated 

GAO to review these surveys, along with the processes, procedures, and 

analyses used by DOD to determine the adequacy of the number of 

health care providers that currently accept nonenrolled TRICARE 

beneficiaries as patients. We have issued several reports in response to 

this mandate,10 including a 2011 report that addressed the department’s 

preliminary efforts to establish an approach to routinely monitor 

nonenrolled beneficiaries’ access to care, among other issues.11

 

7

We include TRICARE Reserve Select beneficiaries in our definition of nonenrolled 

beneficiaries because, although they must enroll in the plan, they receive the same 

benefits as beneficiaries of TRICARE’s Standard and Extra options.

More 

8

The TRICARE Prime option has five access standards that set requirements for the 

following: (1) travel time, (2) appointment wait time, (3) availability and accessibility of 

emergency services, (4) composition of network specialists, and (5) office wait time. See 

32 C.F.R. § 199.17(p)(5) (2013).

9

The mandate directed DOD to conduct these annual surveys for 4 years, beginning in 

fiscal year 2008. See Pub. L. No. 110-181, § 711(a), 122 Stat. 3, 190-91 (2008), H.R. 

Conf. Rep. No. 110-477, at 189-91, 940 (2007), and S. Rep. No. 110-77, at 359-60 

(2007).

10GAO, Defense Health Care: TRICARE Multiyear Surveys Indicate Problems with Access 

to Care for Nonenrolled Beneficiaries, GAO-13-364 (Washington, D.C.: April 2, 2013); 

Defense Health Care: DOD Lacks Assurance That Selected Reserve Members Are 

Informed About TRICARE Reserve Select, GAO-11-551 (Washington, D.C.: June 3, 

2011); Defense Health Care: Access to Civilian Providers under TRICARE Standard and 

Extra, GAO-11-500 (Washington, D.C.: June 2, 2011); Defense Health Care: 2008 Access 

to Care Surveys Indicate Some Problems, but Beneficiary Satisfaction Is Similar to Other 

Health Plans, GAO-10-402 (Washington, D.C.: March 31, 2010).

11See GAO-11-500. 
 

Page 4 GAO-14-384 Assessing Access to Care

recently, in 2013 we reported on the cumulative results of the 

department’s 2008 through 2011 nonenrolled beneficiary and civilian 

provider surveys, and we found that these surveys indicated potential 

problems with access to care for nonenrolled beneficiaries in certain 

locations in all three TRICARE regions.12

To determine the extent to which the TROs have assessed nonenrolled 

beneficiaries’ access to care, we obtained relevant documentation and 

interviewed officials from the TRICARE Management Activity’s (TMA) 

Policy and Operations Directorate, the three TROs, and the three 

contractors. Specifically, we obtained information on how the TROs have 

responded to a DOD 2010 action memo that contained recommendations 

to the TROs on how they should assess nonenrolled beneficiaries’ access 

to civilian providers, including how to analyze and use the results from 

DOD’s surveys of nonenrolled beneficiaries. We also compared this 

memo to the standards described in the Standards for Internal Controls in 

the Federal Government and the related Internal Control Management 

and Evaluation Tool,

This report addresses the extent 

to which the TROs have assessed nonenrolled beneficiaries’ access to 

care.

13

 

12See 

specifically the internal control activities that 

establish performance measures for evaluating and monitoring 

performance. In addition, we reviewed and analyzed data collected by the 

contractors and TMA’s Beneficiary Education & Support Division on 

nonenrolled beneficiaries’ inquiries and complaints. We interviewed 

Beneficiary Education & Support officials and obtained information from 

the contractors about the reliability of the data on beneficiaries’ inquiries, 

and we determined that these data were sufficiently reliable for the 

purposes of our report. Finally, we spoke with representatives from 

military beneficiary organizations to discuss their perspectives on the 

TROs’ efforts to monitor access to care for nonenrolled beneficiaries. 

GAO-13-364. 

13See GAO, Standards for Internal Control in the Federal Government, 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). Internal control is 

synonymous with management control and comprises the plans, methods, and 

procedures used to meet missions, goals, and objectives. The Internal Control 

Management and Evaluation Tool is based on the Standards for Internal Control in the 

Federal Government, and it is intended to provide a systematic approach to assessing an 

agency’s internal control structure. It is one in a series of related documents we have 

issued to assist agencies in improving or maintaining effective operations. See GAO, 

Internal Control Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.: 

August 2001).
 

Page 5 GAO-14-384 Assessing Access to Care

Because the majority of our data collection occurred prior to the 

establishment of DHA on October 1, 2013, we refer to TMA throughout 

most of this report. When relevant, we refer to DHA for activities that 

occurred after that time.

We conducted this performance audit from June 2013 to April 2014 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objective. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objective.

TRICARE provides benefits through several basic options for its nonMedicare-eligible beneficiary population. These options vary by the 

beneficiaries’ locations, enrollment requirements, choices in civilian and 

military treatment facility providers, and required contribution toward the 

cost of their care. For example, beneficiaries living in PSAs can choose 

between TRICARE’s Prime, Standard, and Extra options. In most 

instances, beneficiaries living in non-Prime Service Areas (non-PSA) can 

choose only between TRICARE Standard and TRICARE Extra. Table 1 

provides a summary of some of these benefit options.

Background

TRICARE’s Benefit 

Options
 

Page 6 GAO-14-384 Assessing Access to Care

Table 1: Summary of TRICARE Benefit Options

TRICARE option Description

TRICARE Prime This managed care option requires enrollment, and all active duty servicemembers are 

required to use this option, while other TRICARE beneficiaries have a choice of benefit 

options. TRICARE Prime enrollees receive most of their care from providers at military 

treatment facilities, and also may receive care from network civilian providers. This option 

has the lowest out-of-pocket costs for beneficiaries.

TRICARE Standard and TRICARE Extra TRICARE beneficiaries who choose not to enroll in TRICARE Prime may obtain health 

care from nonnetwork providers (TRICARE Standard) or network civilian providers 

(TRICARE Extra). The TRICARE Standard option is designed to provide beneficiaries 

with maximum flexibility in selecting providers; beneficiaries who obtain care from a 

network provider through TRICARE Extra pay lower copayments than they would under 

the TRICARE Standard option. TRICARE Standard and Extra beneficiaries also may 

receive care from military treatment facilities, though they have a lower priority for 

receiving care at these facilities than do TRICARE Prime enrollees.

TRICARE Reserve Select TRICARE Reserve Select is a premium-based health plan that certain National Guard and 

Reserve members may purchase.a TRICARE Reserve Select beneficiaries may obtain 

health care from either nonnetwork or network providers, similar to beneficiaries using 

TRICARE Standard or Extra, respectively.

Source: GAO analysis of documentation from the Department of Defense.

a

To be eligible for TRICARE Reserve Select, the beneficiary must be a member of the Selected 

Reserve or the Ready Reserve, and not eligible for or enrolled in the Federal Employees Health 

Benefits program, either under their own eligibility or through a family member who is enrolled in a 

family plan.

At the end of fiscal year 2013, TMA identified about 2.2 million 

nonenrolled beneficiaries (approximately 22 percent of the total eligible 

TRICARE population), who fell into three main categories: (1) retirees and 

their dependents, (2) active duty dependents, and (3) non-active duty 

National Guard and Reserve servicemembers and their dependents. (See 

fig. 1.)

Composition of 

TRICARE’s Nonenrolled 

Beneficiary Population
 

Page 7 GAO-14-384 Assessing Access to Care

Figure 1: Types and Percentages of Nonenrolled TRICARE Beneficiaries

Notes: Nonenrolled beneficiaries are beneficiaries not enrolled in TRICARE Prime who are eligible for 

TRICARE’s Standard or Extra options, as well as TRICARE Reserve Select enrollees. Data are for 

nonenrolled beneficiaries as of September 30, 2013, and percentages do not add up to 100 due to 

rounding.

a

Other nonenrolled beneficiaries include inactive Guard and Reserve sponsors who are not enrolled 

in TRICARE Prime, but have a transitional benefit following deactivation.

b

Active duty dependents include dependents of activated National Guard or Reserve 

servicemembers.

Most nonenrolled beneficiaries (81 percent) lived in PSAs at the end of 

fiscal year 2013. However, due to a recent policy change that eliminated 

some PSAs, the percentage of nonenrolled beneficiaries that lived in 

PSAs decreased to 67 percent on October 1, 2013.14

Within the United States, TRICARE is organized into three main 

regions—North, South, and West. (See fig. 2 for a map of the three 

regions.) DHA (formerly TMA) and the TROs are responsible for 

 

14Prior to October 1, 2013, the contractors had the option of developing additional PSAs, 

called Transitional PSAs, which were not located near military treatment facilities or Base 

Realignment and Closure (BRAC) sites. DOD directed the contractors to eliminate the 

Transitional PSAs as of October 1, 2013.

TRICARE Regional 

Structure and Contracts
 

Page 8 GAO-14-384 Assessing Access to Care

managing civilian health care through contractors in each of these 

regions. The TROs, in particular, are responsible for monitoring the 

quality and adequacy of contractors’ provider networks and customersatisfaction outcomes. The TROs also provide customer service to all 

TRICARE beneficiaries who request assistance, regardless of their 

enrollment status.

Figure 2: Location of TRICARE Regions in the United States 

Note: Alaska and Hawaii are in TRICARE’s West region.
 

Page 9 GAO-14-384 Assessing Access to Care

Within their respective PSAs, the contractors in each region are required 

to establish and maintain adequate networks of civilian providers that 

must meet specific access standards for TRICARE Prime beneficiaries in 

five categories—travel time, appointment wait time, availability and 

accessibility of emergency services, composition of network specialists, 

and office wait time.15

Under the current iteration of TRICARE managed care support 

contracts—referred to as TRICARE’s third generation managed care 

support contracts—health care delivery was scheduled to begin 

nationwide on April 1, 2010.

However these access standards do not apply to 

nonenrolled beneficiaries. Nonetheless, the contractors are responsible 

for helping all TRICARE beneficiaries locate providers and for informing 

and educating TRICARE beneficiaries and providers on all aspects of the 

TRICARE program. In addition, they provide customer service to any 

TRICARE beneficiary who requests assistance, regardless of their 

enrollment status.

16 However, due to sustained bid protests for 

each of the contracts and TMA’s implementation of related corrective 

actions, health care delivery started at different times in each of the 

TRICARE regions. TRICARE’s West region was the last of the three 

regions to transition to the third generation of contracts, with a health care 

delivery start date of April 1, 2013.17

 

15See 32 C.F.R. § 199.17(p)(5) (2013).

16TRICARE’s first and second generation managed care contracts were awarded in 

1996/1997 and 2003, respectively.

17The managed care support contract’s health care delivery date in the North region was 

on April 1, 2011, and in the South region on April 1, 2012. For additional information on 

the third generation of TRICARE’s managed care support contracts and the associated 

bid protests, see GAO, Defense Health Care: Acquisition Process for TRICARE’s Third 

Generation of Managed Care Support Contracts, GAO-14-195 (Washington, D.C.: 

March 7, 2014). As described in that report, an offeror—a competitor for a government 

contract—who was not awarded a contract may challenge a federal agency’s award or 

proposed award of a contract based on an alleged violation of statute or regulation. Such 

a challenge, known as a “post award bid protest,” may be filed with the contracting agency 

(referred to as an agency-level protest), the U.S. Court of Federal Claims, or GAO. GAO’s 

bid protest function—in contrast to its audit function—is an adjudicative process that is 

carried out by attorneys in GAO’s Procurement Law group, who prepare bid protest 

decisions resolving disputes concerning the awards of federal contracts.
 

Page 10 GAO-14-384 Assessing Access to Care

In response to requirements contained in the NDAA 2008, TMA 

separately surveyed nonenrolled beneficiaries and civilian providers in 

each of four fiscal years, 2008 through 2011.18

In accordance with the NDAA 2008, TMA identified benchmarks for 

analyzing the results of these surveys. For the 2008 through 2011 

nonenrolled beneficiary survey, TMA used the results of the Department 

of Health and Human Services’ (HHS) Consumer Assessment of 

Healthcare Providers and Systems (CAHPS) health plan survey to create 

eight benchmarks for nonenrolled beneficiaries’ satisfaction with, and 

access to care under, the TRICARE program.

In addition, to conduct the 

required surveys, TMA consulted with representatives of TRICARE 

beneficiaries and health care providers to identify locations where 

nonenrolled beneficiaries have experienced significant access problems, 

and then it oversampled nonenrolled beneficiaries and civilian health care 

providers in these areas. TMA also included specific questions in each 

survey to obtain certain information required by the act. For example, the 

beneficiary survey included questions to determine whether nonenrolled 

beneficiaries have difficulties finding a provider who will accept TRICARE, 

and the civilian provider survey included questions to determine whether 

civilian providers are aware of TRICARE. TMA was allocated nearly 

$5.3 million to administer and analyze the 2008 through 2011 nonenrolled 

beneficiary and civilian provider surveys.

19

 

18The National Defense Authorization Act for Fiscal Year 2012 extended annual 

nonenrolled beneficiary and civilian provider surveys for another 4 years beyond the 

NDAA 2008 requirement, from fiscal years 2012 through 2015. See Pub. L. No. 112-81, 

§ 721(a), 125 Stat. 1298, 1478 (2011).

For the 2008 through 

2011 civilian provider surveys, TMA used the results of its 2005 through 

2007 civilian physician surveys to create seven benchmarks for civilian 

19The CAHPS health plan survey is administered to beneficiaries of commercial health 

insurance, Medicare, Medicaid, and the Children’s Health Insurance Program, by the 

health plans themselves. Results are voluntarily submitted each year to the National 

CAHPS Benchmarking Database, which is maintained by HHS’s Agency for Healthcare 

Research and Quality. 

TMA’s Implementation of 

the NDAA 2008 

Nonenrolled Beneficiary 

and Civilian Provider 

Surveys
 

Page 11 GAO-14-384 Assessing Access to Care

physicians’ awareness and acceptance of TRICARE beneficiaries.20 (See 

app. I for the list of benchmarks for the nonenrolled beneficiary and 

civilian provider surveys.) TMA’s Defense Health Cost Assessment and 

Program Evaluation Division administered the surveys, conducted the 

initial analyses on their results, and presented the results annually to 

relevant internal stakeholders, including the TROs. The TROs were 

responsible for sharing this information with their respective contractors 

and for determining what actions, if any, they and the contractors should 

take in response.

In 2010, the Deputy Chief of TRICARE Policy and Operations issued an 

action memo to the Deputy Director of TMA that outlined four 

recommendations related to nonenrolled beneficiaries’ access to care, 

including the utilization of specific methods for gauging the availability of 

providers for this population. The TROs concurred with the memo’s 

recommendations, and the Deputy Director of TMA approved all but one 

of them. However, we found two of the memo’s approved 

recommendations—which provide the strategy for monitoring and 

assessing nonenrolled beneficiaries’ access to care—do not include 

sufficient guidance that specifies what process to follow or the type of 

criteria to use in determining whether nonenrolled beneficiaries’ access to 

care is adequate. According to federal standards for internal controls, 

having a monitoring strategy that includes specific guidance is important

for leadership to ensure that ongoing monitoring is effective and will 

trigger separate evaluations when problems are identified.21

 

20The National Defense Authorization Act for Fiscal Year 2004 directed DOD to conduct 

surveys of civilian providers, which DOD did in 2005, 2006, and 2007. See Pub. L. 

No. 108-136, § 723, 117 Stat. 1392, 1532 (2003), H.R. Conf. Rep. No. 108-354, at 719 

(2003), and S. Rep. No. 108-46, at 330 (2003). TMA’s 2005 through 2007 civilian 

physician surveys were sent to physicians (civilian primary care and specialty care 

physicians, including psychiatrists). TMA’s 2008 through 2011 civilian provider surveys 

were sent to both physicians and nonphysician mental health care providers (including 

clinical social workers and psychologists).

In the 

absence of such guidance, we found that the TROs’ efforts to implement 

the recommendations have resulted in limited and inconsistent methods 

for identifying and addressing areas with potential access problems, 

which in some instances have included the use of judgment in place of 

clear criteria for making these determinations. Consequently, DHA has no 

21See GAO/AIMD-00-21.3.1.

The TROs’ Efforts to 

Assess Nonenrolled 

Beneficiaries’ Access 

to Care Have Been 

Limited and 

Inconsistent due to 

Insufficient Guidance
 

Page 12 GAO-14-384 Assessing Access to Care

assurance that all potential problem areas are being consistently 

identified and managed across the TRICARE regions.

Each of the action memo’s recommendations and the TROs’ efforts to 

implement them are as follows:

First recommendation: The first recommendation advises the TROs to 

report to the Deputy Director of TMA on the results of the access 

questions from the nonenrolled beneficiary survey for their region, and to 

include any subsequent action plans to address the potential access 

problems they identify. However, this recommendation is silent on the 

type of methodology the TROs should use for analyzing the surveys’ data 

or the specific criteria they should use for determining when their 

analyses should lead to subsequent action.

Without sufficient guidance for implementing this recommendation, we 

found that while the TROs all initially relied on TMA’s analyses of the 

surveys’ data, they varied in the extent to which they used these data to 

identify potential problem areas. Additionally, none of the TROs had a 

clearly documented methodology for how they used these data, including 

a rationale for when further actions should be taken.

• TRO-North officials told us that since 2010 they have used both the 

nonenrolled beneficiary and the civilian provider survey results to 

identify specific locations needing further analysis. Officials explained 

that they initially selected locations in their region that TMA’s analysis 

identified as being below the national average for each of the surveys’ 

benchmarks. According to TRO-North officials, their next step was to 

determine which of these selected locations had more than 500 

nonenrolled beneficiaries, and these locations would be further 

analyzed with the beneficiary population sizing model—an analytical 

approach based on another recommendation in the memo and 

discussed in further detail later in this report.

• TRO-South officials told us that since 2009 they have used TMA’s 

analysis of the nonenrolled beneficiary and civilian provider survey 

results as a basis to identify locations that may need additional action, 

such as outreach to providers. Specifically, using the nonenrolled 

beneficiary surveys’ results, officials told us that they selected the 

locations in their region that TMA’s analysis identified as being below 

the national average for the surveys’ benchmarks. They also selected 

the locations in their region that they identified as being below the 

PSA average on the satisfaction-related questions. Using the results 

of the civilian provider surveys, TRO-South officials explained that 
 

Page 13 GAO-14-384 Assessing Access to Care

they selected the locations in their region that TMA’s analysis 

identified as having lower percentages of civilian providers’ 

awareness and acceptance of TRICARE than the national average for 

those benchmarks. For example, in 2012, after the completion of the 

2008 through 2011 civilian provider surveys, TRO-South officials told 

us that they identified four PSAs in their region that fell below the 

national average for those provider benchmarks, and they asked the 

contractor to determine how to increase civilian provider awareness 

and acceptance in these four PSAs. In response to this request, the 

contractor faxed educational materials about TRICARE to providers in 

those areas to increase their awareness of the program.

• We found that TRO-West officials relied entirely on TMA’s analyses of 

the surveys’ data and did not take steps to further examine these 

data. Specifically, TRO-West officials told us that in 2010 and 2011, 

they asked the contractor to conduct outreach and education to 

providers in any areas in their region that TMA’s analyses had 

identified as falling below the national average for either survey’s 

benchmarks, which the contractor completed. TRO-West officials told 

us that they also asked the contractor to conduct similar education 

and outreach efforts in late 2012. According to a TRO-West official, 

however, the region was transitioning to a new contractor in 2012, and 

the outgoing contractor no longer provided reports of these education 

and outreach efforts; as a result, the TRO was unable to provide 

documentation that these efforts were completed.22

Second recommendation: The second recommendation advises the 

TROs to establish a working group to adapt and standardize, to the extent 

possible, a beneficiary population-to-provider model to determine whether 

there are sufficient numbers of civilian providers to provide reasonable 

access to care. This model was to be based on the beneficiary population 

sizing model that had been independently developed by TRO-West to 

assess access to care for nonenrolled beneficiaries in the West region. 

The TRO-West model was designed to analyze locations with 500 or 

more nonenrolled beneficiaries and evaluate access to care using the 

Graduate Medical Education National Advisory Committee standards to 

estimate the appropriate number of required civilian providers based on a 

 

22The West region began transitioning to a new contractor in July 2012 and completed the 

transition in April 2013.
 

Page 14 GAO-14-384 Assessing Access to Care

population-to-provider ratio.23 Each TRO is to report to the Deputy 

Director of TMA on the results of its analysis, as well as provide action 

plans to address specific areas where the model identified potential 

access issues. In 2011, we found that each TRO had developed a model 

that generally followed the same methodology and included similar data 

as the TRO-West model with some regional variation. At that time, we 

reported that the TROs’ models seemed reasonable, but that because

they had only begun their implementation, it was too early to determine 

their effectiveness.24

In this review, we found that the TROs’ models have evolved, and that 

only TRO-West continues to use the original approach of applying criteria 

to population-to-provider ratios. The other two TROs mapped beneficiaryto-provider population densities in selected locations, but were not 

applying criteria to these data to identify potential problem areas. Instead, 

these TROs have used the mapping results along with additional 

information, such as beneficiary complaints and their contractor’s reports 

on network adequacy as a basis for determining areas with potential 

access problems. Officials from these TROs told us that their approach 

was more multifaceted than the original model. However, in the absence 

of criteria, we found that they ultimately relied on their judgment to 

determine that no access problems existed in their regions. Additionally, 

TRO-West officials told us that even when their model’s criteria identified 

areas with potential access problems for certain medical specialties, they 

used their judgment to determine that no access problems existed. 

Without clear criteria for identifying areas with potential access problems 

and determining whether additional action is needed, there is no 

assurance that the TROs’ models are useful or consistent in gauging and 

addressing nonenrolled beneficiaries’ access to care.

• TRO-North officials applied their model to the counties they identified 

through their analyses of the 2008 through 2011 nonenrolled 

beneficiary and civilian provider surveys’ results, which consisted of 

16 counties in 2012. For each identified location, TRO-North officials 

explained that they analyzed TRICARE claims over the previous 

 

23The Graduate Medical Education National Advisory Committee projected the need for 

and supply of physicians and other providers and developed guidelines for the geographic 

distribution of physicians. A key assumption in the model is that the providers will agree to 

treat the next nonenrolled beneficiary seeking treatment.

24See GAO-11-500. 
 

Page 15 GAO-14-384 Assessing Access to Care

12 months to determine the number of network and nonnetwork 

civilian providers in more than 25 specialty categories. Officials then 

mapped each location with nonenrolled beneficiary and civilian 

provider densities and used their judgment to determine whether the 

area had potential access problems. Specifically, they made this 

determination by correlating the model’s results with other relevant 

information, including results from other beneficiary surveys, 

nonenrolled beneficiaries’ correspondence to the TRO, and input from 

military treatment facility commanders. Based on this approach, TRONorth officials told us that they had not identified any locations of 

concern since they began using the model in 2010. However, these 

officials could not clearly describe the criteria for what constitutes an 

adequate number of providers in each area, or what information from 

the additional sources would indicate a potential access problem, 

triggering the need to develop and implement a plan of action for a 

particular location.

• TRO-South officials applied their model to the top 25 counties in their 

region that they identified as having at least 500 nonenrolled 

beneficiaries. For each county, TRO-South officials analyzed 

TRICARE claims submitted over the previous 12 months to determine 

the number of network and nonnetwork civilian providers by four 

broad specialty categories.25

 

25These four categories (primary care, orthopedics, obstetrics and gynecology, and 

mental health) included many of the same specialties analyzed in TRO-North’s model.

Officials then mapped each location with 

nonenrolled beneficiary and civilian provider densities to determine if 

all counties with high beneficiary concentrations also had a high 

provider density. For example, the map uses incremental shading to 

depict the number of beneficiaries in four categories (500 to 999 

beneficiaries, 1,000 to 4,999, 5,000 to 9,999, and 10,000 to 22,000) 

and the number of providers from 1 to 3,000. Based on the results of 

the mapping, along with a review of beneficiary complaints, officials 

told us that they used their judgment to determine whether any of the 

locations had potential access problems. Officials stated that based 

on the mapping results and the small number of beneficiary 

complaints they have received, they have not identified any locations 

with potential access problems since they began using the model in 

2011. However, TRO-South officials could not clearly describe what 

criteria they used in making this determination, including what 

concentration of beneficiaries should have what density of providers in 

each area, or what defined a “small number” of complaints.
 

Page 16 GAO-14-384 Assessing Access to Care

• TRO-West officials applied their model to zip codes that they identified 

as having more than 500 nonenrolled beneficiaries, which consisted 

of 68 groups of zip codes in 2013. For each of these groups, TROWest officials analyzed TRICARE claims submitted over the previous 

13 months to determine the number of network and nonnetwork 

civilian providers by 27 specialty categories. TRO-West officials 

explained that they use this information to calculate a ratio of 

nonenrolled beneficiaries to civilian providers, by specialty category, 

in each of the groups of zip codes included in the analysis. Using the 

Graduate Medical Education National Advisory Committee model’s 

ratios, TRO-West officials found that each of the 68 groups of zip 

codes had at least one specialty group that fell below the ratio, 

meaning that these areas may not have an adequate number of 

civilian provider specialties to meet the needs of the areas’ 

nonenrolled beneficiary population. However, TRO-West officials told 

us that they used their judgment to determine that they did not need to 

take any actions because they had not received any inquiries or 

complaints from nonenrolled beneficiaries, military treatment facility 

commanders, or congressional staff about access problems in these 

locations.26

Third recommendation: The third recommendation involved a 

modification to the managed care support contracts that would require the 

contractors to provide the TROs with standardized reports about access 

inquiries and complaints received from nonenrolled beneficiaries. It also 

recommended that the TROs report to the Deputy Director of TMA on the 

results of these reports, including the TROs’ development of action plans 

to address any access issues identified in the reports. The Deputy 

Director of TMA did not approve this recommendation and cited a lack of 

evidence that it would provide a result that had a return on investment.

Nonetheless, as we have previously reported, TMA and the contractors 

already collect data on complaints and inquiries for all beneficiaries, 

including nonenrolled beneficiaries.27

 

26In addition, TRO-West officials also use the model to compile a list of network and 

nonnetwork providers in these areas that can be used as a provider directory when 

nonenrolled beneficiaries inquire about finding a civilian provider in these locations.

However, TMA has cautioned us 

that these data are not representative because not all beneficiaries will 

communicate when they have a question or complaint. Our analysis of 

27See GAO-11-500. 
 

Page 17 GAO-14-384 Assessing Access to Care

the Beneficiary Education & Support Division’s and the contractors’ data 

found that of those nonenrolled beneficiaries who made a complaint or 

inquiry, access to care was a relatively minor issue for fiscal years 2011 

through 2013.28 For example, about 6 percent of inquiries and complaints 

documented in the Beneficiary Education & Support Division’s database 

during this time were from nonenrolled beneficiaries, and of those, less 

than 1 percent were related to access to care. Additionally, of the access 

complaints received by contractors in fiscal year 2013, about 2 percent in 

the South region and about 5 percent in the North region were from 

nonenrolled beneficiaries.29

Fourth recommendation: The fourth recommendation advises TMA to 

establish the capability for beneficiaries to search online for nonnetwork 

civilian providers within the continental United States. However, when we 

previously reported on this effort in 2011, we noted that TMA did not have 

sufficient data to develop this online search tool.30 Instead, TMA officials 

decided that under the current generation of TRICARE contracts, each 

contractor would be responsible for creating an online provider directory 

for its region that would include information for beneficiaries on 

TRICARE-authorized providers, both network and nonnetwork. Officials 

told us that by early 2013, each of the three region’s contractors had 

produced an online nonnetwork civilian provider directory.

TMA has devoted significant resources over the past decade—largely 

through national surveys of beneficiaries and civilian providers—in 

determining whether nonenrolled beneficiaries have adequate access to 

health care. However, the lack of access standards for this population has 

significantly limited the department’s ability to make these determinations. 

While identifying access problems and taking action are largely the 

responsibility of the TROs, TMA’s guidance to them lacked the level of 

specificity needed for conducting the recommended analyses of the 

available data, including from the beneficiary and provider surveys and 

 

28DOD’s Beneficiary Education and Support division was a part of TMA prior to October 1, 

2013.

29The West region’s contractor began health care delivery on April 1, 2013, and the 

inquiries and complaints from this contractor could not yet be separated by beneficiary 

type.

30GAO-11-500. 

Conclusions
 

Page 18 GAO-14-384 Assessing Access to Care

the beneficiary population sizing model. Furthermore, TMA’s guidance for 

these analyses also lacked criteria for clearly identifying areas with 

potential access problems. Not only did this result in inconsistent and 

limited efforts across the regions, but TRO officials relied predominantly 

on their own judgment to determine whether access problems existed. In 

many instances, officials cited the number of beneficiary complaints—an 

admittedly unreliable measure—as a key factor in determining that there 

were no access problems even when the data indicated otherwise. 

Although TMA established a framework for the TROs to assess 

nonenrolled beneficiaries’ access to care, more-specific guidance for 

conducting these analyses and interpreting their results would provide a 

more rigorous and consistent approach across the regions for identifying 

areas with potential access problems and determining whether actions 

should be taken, in accordance with internal control standards for 

effective monitoring. Without such guidance, DHA—which assumed 

oversight responsibility for TRICARE in 2013—cannot provide reasonable 

assurance that the TROs’ efforts to assess access to care for nonenrolled 

beneficiaries are effective or that its own efforts to field and analyze large, 

costly surveys are providing useful data.

We recommend that the Secretary of Defense require the Director of DHA 

to enhance existing guidance for the TROs to include more specificity on 

assessing nonenrolled beneficiaries’ access to care. Specifically, the 

guidance should contain criteria for analyzing and interpreting the 

nonenrolled beneficiary and civilian provider surveys’ results and the 

beneficiary population sizing model to facilitate a more rigorous and 

consistent approach across regions for identifying locations with potential 

access problems and determining whether actions should be taken.

We provided a draft of this report to DOD for comment. DOD concurred 

with our finding, conclusions, and recommendation. DOD stated that the 

Director of DHA will enhance guidance to the TROs to include more 

specificity on assessing nonenrolled beneficiaries’ access to care. 

However, DOD did not provide a time frame for when this guidance would 

be developed.

DOD’s comments are reprinted in appendix II. DOD did not provide any 

technical comments.

Recommendation for 

Executive Action

Agency Comments
 

Page 19 GAO-14-384 Assessing Access to Care

We are sending copies of this report to the Secretary of Defense, the 

Director, Defense Health Agency, and appropriate congressional 

committees. The report is also available at no charge on GAO’s website 

at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff members who made key contributions to 

this report are listed in appendix III.

Debra A. Draper

Director, Health Care
Appendix I: Benchmarks for TRICARE 

Management Activity’s 2008 through 2011 

Surveys

Page 20 GAO-14-384 Assessing Access to Care

In accordance with the National Defense Authorization Act for Fiscal Year 

2008 (NDAA 2008), the Department of Defense’s TRICARE Management 

Activity (TMA) identified benchmarks for analyzing the results of the 

nonenrolled beneficiary and civilian provider surveys.1 Because TMA 

based some of its nonenrolled beneficiary survey questions on those 

included in the Department of Health and Human Services’ (HHS) 

Consumer Assessment of Healthcare Providers and Systems (CAHPS) 

health plan survey, it was able to compare the results of those questions 

with its 2008 through 2011 nonenrolled beneficiary survey results.2

Table 2: TRICARE Management Activity (TMA) Benchmarks for Its 2008 through 

2011 Nonenrolled Beneficiary Surveys

This 

resulted in eight benchmarks for nonenrolled beneficiaries’ satisfaction 

with, and access to care under, the TRICARE program. Table 2 lists the

eight benchmarks.

Benchmark categories Benchmark (percentage)

Global ratings (rating of 8 or higher on a 0-10 scale)

1. Rating of health plan 64a

2. Rating of health care 77a

3. Rating of personal doctor 76a

4. Rating of specialist doctor 77a

Access ratings

5. Access to personal doctor 69b

6. Access to specialist doctor 77b

7. Getting needed care 79c

8. Getting care quickly 79d

Source: GAO analysis of data from TMA.

 

1

Prior to October 1, 2013, TMA oversaw the TRICARE program. In response to increasing 

pressure on its budgetary resources, DOD established the Defense Health Agency (DHA) 

on October 1, 2013, to assume management responsibility of numerous functions of its 

medical health system, including the former TMA, which was terminated on that date. For 

additional information about the establishment of DHA, see GAO, Defense Health Care 

Reform: Additional Implementation Details Would Increase Transparency of DOD’s Plans 

and Enhance Accountability, GAO-14-49 (Washington, D.C.: November 2013).

2

The CAHPS health plan survey is administered to beneficiaries of commercial health 

insurance, Medicare, Medicaid, and the Children’s Health Insurance Program, by the 

health plans themselves. Results are voluntarily submitted each year to the National 

CAHPS Benchmarking Database, which is maintained by HHS’s Agency for Healthcare 

Research and Quality.

Appendix I: Benchmarks for TRICARE 

Management Activity’s 2008 through 2011 

Surveys
Appendix I: Benchmarks for TRICARE 

Management Activity’s 2008 through 2011 

Surveys

Page 21 GAO-14-384 Assessing Access to Care

Notes: Information in this table is based on interviews with TMA officials, and we did not verify that 

the methods for determining the benchmarks were accurate. TMA used the results of the Department 

of Health and Human Services’ (HHS) Consumer Assessment of Healthcare Providers and Systems 

(CAHPS) health plan surveys as its benchmarks. The CAHPS health plan survey is administered to 

beneficiaries of commercial health insurance, Medicare, Medicaid, and the Children’s Health 

Insurance Program, by the health plans themselves. Results are voluntarily submitted each year to 

the National CAHPS Benchmarking Database, which is maintained by HHS’s Agency for Healthcare 

Research and Quality.

a

This percentage is based on the national average for commercial beneficiaries, adjusted to match 

the age and health status of TRICARE Standard respondents, who answered with a rating of 8 or 

higher in the 2006 version of the CAHPS health plan survey. For rating of health plan: “Using any 

number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan 

possible, what number would you use to rate your health plan?” For rating of health care: “Using any 

number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care 

possible, what number would you use to rate all of your health care in the last 12 months?” For rating 

of personal doctor: “Using any number from 0 to 10, where 0 is the worst personal doctor or nurse 

possible and 10 is the best personal doctor or nurse possible, what number would you use to rate 

your personal doctor or nurse?” For rating of specialist doctor: “Using any number from 0 to 10, where 

0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to 

rate the specialist? (For the specialist you saw most often in the last 12 months).”

b

This percentage is based on the national average for commercial beneficiaries, adjusted to match 

the age and health status of TRICARE Standard respondents, who answered “not a problem” in the 

2006 version of the CAHPS health plan survey. For access to personal doctor: “Since you joined your 

health plan, how much of a problem, if any, was it to get a personal doctor or nurse you are happy 

with?” For access to specialist doctor: “In the last 12 months, how much of a problem, if any, was it to 

see a specialist that you needed to see?”

c

This percentage is based on the average of the adjusted national averages for access to personal 

doctor, access to specialist doctor, and two other averages about access or delays: (1) beneficiaries 

who answered “not a problem” to the question that asked “In the last 12 months, how much of a 

problem, if any, was it to get the care, tests or treatment you or a doctor believed necessary?” 

(2) beneficiaries who either answered “no” to the question that asked “In the last 12 months, did you 

need approval from your health plan for any care, tests, or treatment?” or “no problem” to the 

question that asked “In the last 12 months, how much of a problem, if any, were delays in health care 

while you waited for approval from your health plan?” 

d

This percentage is based on the national average for commercial beneficiaries, adjusted to match 

the age and health status of TRICARE Standard respondents, who answered “usually” or “always” to 

the question “In the last 12 months, when you needed care right away for an illness, injury, or 

condition, how often did you get care as soon as you wanted?” in the 2006 version of the CAHPS 

health plan survey.

To establish benchmarks for its civilian provider survey, TMA compared 

the results of its 2008 through 2011 civilian provider surveys with the 

results of its 2005 through 2007 civilian physician surveys.3

 

3

The National Defense Authorization Act for Fiscal Year 2004 directed DOD to conduct 

surveys of civilian providers, which DOD did in 2005, 2006, and 2007. See Pub. L. 

No. 108-136, § 723, 117 Stat. 1392, 1532 (2003), H.R. Conf. Rep. No. 108-354, at 719 

(2003), and S. Rep. No. 108-46, at 330 (2003). TMA’s 2005 through 2007 civilian 

physician surveys were sent to physicians (civilian primary care and specialty care 

physicians, including psychiatrists). TMA’s 2008 through 2011 civilian provider surveys 

were sent to both physicians and nonphysician mental health care providers (including 

clinical social workers and psychologists).

This resulted 
Appendix I: Benchmarks for TRICARE 

Management Activity’s 2008 through 2011 

Surveys

Page 22 GAO-14-384 Assessing Access to Care

in seven benchmarks for civilian providers’ awareness and acceptance of 

TRICARE beneficiaries. Table 3 lists these seven benchmarks.

Table 3: TRICARE Management Activity (TMA) Benchmarks for Its 2008 through 2011 Civilian Provider Surveys

Benchmark category Benchmark (percentage)

1. Civilian physicians’ awareness 87a

2. Civilian physicians’ acceptance of new patients 92b

3. Civilian physicians’ acceptance of new TRICARE Standard patients (for all claims or on a claimby-claim basis only) 76c

4. Civilian physicians’ acceptance of new TRICARE Standard patients (for all claims), if they are 

accepting new TRICARE Standard patients 91d

5. Civilian physicians’ acceptance of new TRICARE Standard patients, if they are accepting any 

new patients 81e

6. Civilian physicians’ acceptance of new Medicare patients 88f

7. Civilian physicians’ acceptance of new TRICARE Standard patients, if they are accepting new 

Medicare patients 87g

Source: GAO analysis of data from TMA.

Notes: Information in this table is based on interviews with TMA officials, and we did not verify that 

the methods for determining the benchmarks were accurate. TMA used the results of its 2005 through 

2007 surveys of civilian physicians, which were sent to physicians only (civilian primary care and 

specialty care physicians, including psychiatrists), and did not include nonphysician mental health 

providers, such as clinical social workers and psychologists. TMA’s 2008 through 2011 civilian 

provider surveys were sent to both physicians and nonphysician mental health care providers.

a

This percentage is based on the national average of respondents that answered yes to the following 

question: “Is the provider aware of the TRICARE health care program?”

b

This percentage is based on the national average of respondents that answered yes to the following 

question: “As of today, is the provider accepting any new patients?”

c

This percentage is based on the national average of respondents that answered “for all claims” or on 

a “claim-by-claim basis” to the following question: “As of today, is the provider accepting new 

TRICARE Standard patients?”

d

This percentage is based on the national average of respondents that answered “Yes, for all claims” 

to the following question: “As of today, is the provider accepting new TRICARE Standard patients?” 

and yes to the following question: “As of today, is the provider accepting new TRICARE Standard 

patients?”

e

This percentage is based on the national average of respondents that answered yes to the following 

questions: “As of today, is the provider accepting any new patients?” and “As of today, is the provider 

accepting new TRICARE Standard patients?” The yes response to this question represents providers’ 

indications that they were accepting new TRICARE Standard patients on either a “claim-by-claim 

basis” or “for all claims.”

f

This percentage is based on the national average of respondents that answered yes to the following 

question: “As of today, is the provider accepting new Medicare patients?”

g

This percentage is based on the national average of respondents that answered yes to the following 

questions: “As of today, is the provider accepting new Medicare patients?” and “As of today, is the 

provider accepting new TRICARE Standard patients?” The yes response to this question represents 

providers’ indications that they were accepting new TRICARE Standard patients on either a “claimby-claim basis” or “for all claims.” 
Appendix II: Comments from the Department 

of Defense

Page 23 GAO-14-384 Assessing Access to Care

Appendix II: Comments from the Department 

of Defense
Appendix II: Comments from the Department 

of Defense

Page 24 GAO-14-384 Assessing Access to Care
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 25 GAO-14-384 Assessing Access to Care

Debra Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Bonnie Anderson, Assistant 

Director; Danielle Bernstein; Jacquelyn Hamilton; Jeffrey Mayhew; and 

Laurie Pachter made key contributions to this report.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291141)
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